Instructions for Candidate:-

1. There are 5 sheets in this file.

2. This sheet (Sheet - 1) is to be retained by you carefully.
3. Your Login id is AKAS20091
4. Remember your password and do not disclose it to anyone.
5. Sheet - 2 is the Application Form to be sent by Registered / Speed Post only to IIT MADRAS ZONE
a. Stick your color photo at the designated place.
b. Put your signature at the two designated places.
c. Get the signature of your Parent / Guardian at the designated place.
6. Sheet - 3 is the Application Form and should be retained by you for your reference.
7. You have selected NEFT mode for payment. The details for the fund transfer are in Sheet 5 of this form.At the end
of fund transfer, note down the Unique Transaction ID/ Reference no. (UTR) in the top left corner of the Application
form (Sheet 2).
8. Attach attested copies of Tenth Class/SSLC certificate where your date of birth is mentioned clearly, and all other
applicable certificates (SC/ST/PD/DS/Enlarged Font request).
9. Insert completed Application Form with enclosures (if any) into an A4 size envelope. DO NOT FOLD THE
APPLICATION.
10. Sheet - 4 contains the address of the IIT MADRAS ZONE
to which the application form needs to be posted.
11. Stick the Sheet-4 on top of the A4 size envelope and post it.
12. The packet should reach the corresponding zonal IITs on or before 20th December 2010.

Sheet - 1
 IIT COPY
APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2011
Application No: B361095597 Zone: IIT MADRAS ZONE Payment Mode: NEFT (UTR ____________________ )

1. Name of the Candidate as in AKASH P 17. Name of one Parent / PRASANNAKUMAR G K

the 10th Class Certificate Guardian
as in 10th Class Certificate
2. Category General
18. Place of 10th Schooling CITY
3. Gender MALE
19. Type of Preparation SELF STUDY
4. Nationality INDIAN
20. Board of Qualifying STATE BOARD
5. Year of Passing Qualifying Appearing in 2011
Examination
Examination 10+2
Class or Equivalent For the First 21. Phone / Mobile 08192234621
Time Number
22. Mother Tongue Kannada
In the above examination did you Not Applicable
obtain qualifying marks? 23. Pincode or Permanent 577006
6. Earlier Attempts at JEE NONE Place of Residence
24. Parent's / Guardian's Private Service
7. Sub Category None Occupation
8. Requirement of Enlarged Font No 25. Parent's / Guardian's BOTH PARENTS GRADUATE
Question Papers Educational Background
9. Date of Birth (DD/MM/YYYY) 20/09/1993 26. Parent's / Guardian's Total BELOW Rs.1,00,000
Annual Income
10. Year of passing 10th Class 2009
or Equivalent
11. Choice of Examination 610 - Mysore
Cities 608 - Bangalore
12. Counselling IIT MADRAS

13. Question Paper Language ENGLISH

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. I have read the
Information Brochure and I shall abide by the terms and conditions therein. I also certify that I have not appeared in JEE in 2009 or earlier
and neither taken admission nor paid the registration fee at any of the IITs, IT-BHU or ISM-DHANBAD. In the event of suppression or
distortion of any fact regarding the eligibility criteria, nationality etc., in my application form, I understand that I will be denied the
opportunity to appear in JEE and if already admitted, my admission/degree acquired is liable for cancellation. I also understand that the
decision of the Joint Admission Board regarding my admission to IITs/IT-BHU/ISM-DHANBAD is final and I shall abide by the decision.
Further, if admitted, I promise to abide by the rules and norms of discipline of the Institute I join.

Place:

Date:
Signature of the Candidate
Name of the Parent / PRASANNAKUMAR G K
Guardian
Name of the Candidate AKASH P
Countersigned by Parent / Guardian

14. Address:- #3371/27-E/9A 15. Photograph

SECOND MAIN, FOURTEENTH CROSS

VINOBANAGAR

DAVANGERE,KARNATAKA
Please write
Phone / Mobile 08192234621 your name and
Number application
Pincode 577006 number on the
back of photo
E-Mail Address gkpkumar@bsnl.in before affixing

16. Signature of the candidate

Signature(within box) in running hand using

B361095597 black ball point pen only (do not sign in capitals)
Send this form along with the necessary documents to IIT MADRAS ZONE

Sheet - 2
 CANDIDATE COPY
APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2011
Application No: B361095597 Zone: IIT MADRAS ZONE Payment Mode: NEFT (UTR ____________________ )

1. Name of the Candidate as in AKASH P 17. Name of one Parent / PRASANNAKUMAR G K

the 10th Class Certificate Guardian
as in 10th Class Certificate
2. Category General
18. Place of 10th Schooling CITY
3. Gender MALE
19. Type of Preparation SELF STUDY
4. Nationality INDIAN
20. Board of Qualifying STATE BOARD
5. Year of Passing Qualifying Appearing in 2011
Examination
Examination 10+2
Class or Equivalent For the First 21. Phone / Mobile 08192234621
Time Number
22. Mother Tongue Kannada
In the above examination did you Not Applicable
obtain qualifying marks? 23. Pincode or Permanent 577006
6. Earlier Attempts at JEE NONE Place of Residence
24. Parent's / Guardian's Private Service
7. Sub Category None Occupation
8. Requirement of Enlarged Font No 25. Parent's / Guardian's BOTH PARENTS GRADUATE
Question Papers Educational Background
9. Date of Birth (DD/MM/YYYY) 20/09/1993 26. Parent's / Guardian's Total BELOW Rs.1,00,000
Annual Income
10. Year of passing 10th Class 2009
or Equivalent
11. Choice of Examination 610 - Mysore
Cities 608 - Bangalore
12. Counselling IIT MADRAS

13. Question Paper Language ENGLISH

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. I have read the
Information Brochure and I shall abide by the terms and conditions therein. I also certify that I have not appeared in JEE in 2009 or earlier
and neither taken admission nor paid the registration fee at any of the IITs, IT-BHU or ISM-DHANBAD. In the event of suppression or
distortion of any fact regarding the eligibility criteria, nationality etc., in my application form, I understand that I will be denied the
opportunity to appear in JEE and if already admitted, my admission/degree acquired is liable for cancellation. I also understand that the
decision of the Joint Admission Board regarding my admission to IITs/IT-BHU/ISM-DHANBAD is final and I shall abide by the decision.
Further, if admitted, I promise to abide by the rules and norms of discipline of the Institute I join.

Place:

Date:
Signature of the Candidate
Name of the Parent / PRASANNAKUMAR G K
Guardian
Name of the Candidate AKASH P
Countersigned by Parent / Guardian

14. Address:- #3371/27-E/9A 15. Photograph

SECOND MAIN, FOURTEENTH CROSS

VINOBANAGAR

DAVANGERE,KARNATAKA
Please write
Phone / Mobile 08192234621 your name and
Number application
Pincode 577006 number on the
back of photo
E-Mail Address gkpkumar@bsnl.in before affixing

16. Signature of the candidate

Signature(within box) in running hand using

B361095597 black ball point pen only (do not sign in capitals)

Sheet - 3
APPLICATION FORM NO B 3 6 1 0 9 5 5 9 7 BY REGISTERED POST/
SPEED POST
FOR Rs. 900 /-

JEE - 2011
Indian Institutes of Technology

Your Choice Choice - I Choice - II

of Cities
for JEE - 2011 610 608

To
From
Name AKASH P
The Chairman
Address Joint Entrance Examination - 2011
Indian Institute of Technology - IIT MADRAS ZONE
#3371/27-E/9A

SECOND MAIN, FOURTEENTH CROSS IIT MADRAS

VINOBANAGAR CHENNAI

DAVANGERE,KARNATAKA

Pin 5 7 7 0 0 6

Phone/Mobile: 08192234621
Email (if any) : gkpkumar@bsnl.in Pin 6 0 0 0 3 6

Sheet - 4
 JEE-2011 NEFT Transaction

1. Payee / Beneficiary / Recipient Bank Name : Indian Bank

2. Payee / Beneficiary / Recipient Branch Name : Adyar

3. Bank's IFSC Code: IDIB000A002

4. Payee / Beneficiary / Recipient Name: I I T (MADRAS) JEE-2011 (NEFT A/C)

5. Payee / Beneficiary / Recipient Account No : 910646450

6. Payee / Beneficiary / Recipient Account Type: Current Account

7. Application Fee (Exclusive of other bank Rs. 900 /-

charges):

Please enter your name and application number (B361095597) in the Remitter's Account Details/Customer
Transaction Details or equivalent fields in the NEFT request form

The counterfoil from bank or confirmation for Internet Transfer (UTR number) should be attached with this
sheet and sent to IIT

Sheet - 5